The Laryngoscope

C 2015 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Migraine Features in Patients With Meniere’s Disease

Yaser Ghavami, MD; Hossein Mahboubi, MD, MPH; Amy Y. Yau, MD; Marlon Maducdoc, BS;
Hamid R. Djalilian, MD

Objectives/Hypothesis: To better understand the features of migraine in Meniere’s disease (MD).

Study Design: Retrospective review of prospectively obtained surveys in an outpatient clinic of a tertiary medical
center.
Methods: Detailed questionnaires on headaches and dizziness were given to consecutive patients presenting with dizzi-
ness. The responses were verified by the clinician with the patient. The data, in addition to the clinical history and audio-
gram, were used to diagnose patients with migraine headaches and MD using criteria set by the International Headache
Society (IHS) and the American Academy of Otolaryngology–Head and Neck Surgery, respectively. The prevalence of migraine-
like symptoms in those patients with MD, who did not fit the diagnostic criteria for migraine, was evaluated.
Results: Thirty-seven patients with definite MD were included. There was a predominance of females (female/male:26/
11). Mean age of patients was 52 6 14 years. Nineteen patients (51%) had migraine headaches. Fifteen patients fulfilled the
criteria for definite vestibular migraine. Of those who did not fulfill the IHS migraine criteria, a majority had characteristics
such as a family history of migraine, visual motion sensitivity, or lifelong motion sickness that were highly suggestive of a
migraine disorder.
Conclusions: A majority of patients with MD have migraine headaches as defined by the IHS. Sensitivity to visual
motion, light and sound, head motion, smells, weather changes, or medication was present in 95% of all patients with definite
MD and 82% of non-IHS migraine MD patients. This may suggest that MD may be an atypical variant of migraine.
Key Words: Meniere’s disease, migraine-related vestibulopathy, vestibular migraine.
Level of Evidence: 4
Laryngoscope, 126:163–168, 2016

INTRODUCTION distinguish the two conditions. Diagnosis is primarily based

Several studies have shown that there is significant
overlap between the symptoms of vestibular migraine
(VM) and those of Meniere’s disease (MD).1–3 Patients
with VM may experience symptoms of MD including epi-
sodic vertigo, tinnitus, constant or fluctuating sensorineu-
ral hearing loss (SNHL), and/or aural fullness.1 Dizziness
attacks are seen in a majority of VM patients, and these
attacks are independent of headaches.2 Therefore, some-
times patients with VM are misdiagnosed as MD
patients.3 In these circumstances, differentiation of these
two diseases is often difficult. Currently, there are no
known definitive diagnostic tests that can reliably
From the Division of Otology, Neurotology, and Skull Base Sur-
gery, Department of Otolaryngology–Head and Neck Surgery (Y.G., H.M.,
A.Y.Y., M.M., H.R.D.), and Department of Biomedical Engineering (H.R.D.),
University of California, Irvine, Irvine, California, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
March 30, 2015.
Presented at the American Neurotology Society Annual Meeting at
COSM, Las Vegas, Nevada, U.S.A., May 14–18, 2014.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Yaser Ghavami, MD, Hossein Mahboubi, MD, and Amy Y. Yau,
MD, contributed equally to this work.
Send correspondence to Hamid R. Djalilian, MD, Director, Division
of Otology, Neurotology and Skull Base Surgery, Department of Otolar-
yngology–Head and Neck Surgery, University of California Irvine,
Otolaryngology-5386, 19182 Jamboree Road, Irvine, CA 92697.
E-mail: hdjalili@uci.edu
DOI: 10.1002/lary.25344
on clinical criteria. MD is diagnosed by the American Acad-
emy of Otolaryngology–Head and Neck Surgery (AAO-
HNS) criteria,4 and VM is diagnosed based on the criteria
defined by the International Headache Society (IHS).5
The overlap of MD and VM has been described by a
multitude of authors. Rassekh and Harker found a
migraine prevalence of 81% in patients with vestibular
MD compared with 22% in patients with classic MD.6
These groupings of vestibular and classical MD, as well
as cochlear and vestibular MD, have fallen out of favor,
and the Committee on Hearing and Equilibrium of the
AAO-HNS had recommended that these cochlear or ves-
tibular variants of MD be excluded from classical MD.7
The AAO-HNS suggested that this phenomenon of recur-
rent vestibulopathy without hearing loss was not related
to the same pathological disorder of classical MD of idio-
pathic endolymphatic hydrops. Parker also recognized
that migraine occurs more often in patients with MD
than in the general population, and that the classical
symptoms of MD and migraine may be related.8 A com-
mon genetic and vascular origin of migraine and MD
was proposed, where abnormal blood flow to the brain,
cochlea, and vestibule can cause paroxysmal cochlear
and vestibular symptoms. Minor et al. noted that there
are similarities in the presentations of patients with
migraine and MD.9 There is clearly a significant overlap
between VM and MD, which may suggest that the two
conditions may be variants of each other.

Laryngoscope 126: January 2016 Ghavami et al.: Migraine Features in Patients With MD
163
 It has been observed that patients with VM gener-
ally had normal pure-tone average hearing, whereas
patients with definite MD had significantly worse pure-
tone average hearing, especially in the lower frequen-
cies. Based on this observation, it has been recom-
mended that SNHL be the main characteristic in
distinguishing the two disorders.10 However, it was
noted that there were several patients with definite MD
according to the AAO-HNS criteria who presented with
normal hearing, though a review of later audiograms
identified a low-frequency sensorineural hearing loss.10
Additionally, there were VM patients with hearing loss.
These patients with VM improved with migraine pro-
phylactic medications. The cochlear symptoms of VM
include tinnitus, aural fullness, and hearing loss that
may fluctuate, as with MD. The vestibular manifesta-
tions of VM are variable, ranging from true vertigo, with
episodic vertigo attacks, motion sensitivity, and chronic
nonspecific vestibulopathy.9,10
In our practice, we have found that the vast major-
ity of the patients with MD also have histories that are
consistent with the presence of migraine. These patients,
however, may not completely fulfill the IHS criteria for
migraine headaches with or without aura. In this study,
we set out to determine the prevalence of migraine head-
aches as defined by the IHS criteria in our Meniere’s dis-
ease cohort. In addition, we specifically examined the
characteristics of the MD patients who did not fulfill the
criteria for migraine to determine the frequency of other
migraine-related characteristics without the IHS defini-
tion of migraine.
MATERIALS AND METHODS
Patients
All adult patients who presented to the neurotology clinic
at our institution with a complaint of dizziness between April
2013 and January 2014 were asked to fill out a questionnaire
detailing their dizziness, headaches (if any), and other
migraine-related symptoms. Patients with a diagnosis of MD
based on the AAO-HNS criteria were included in our study.4
Criteria were met using clinical evaluation, questionnaire, the
audiogram, and vestibular testing (when available) (Table I). If
a patient’s diagnosis remained uncertain, his/her record was
excluded from the analysis. Institutional review board approval
was obtained from our institution.
Data Collection
A written questionnaire was developed based on the crite-
ria set by the IHS for migraine with and without aura, VM,
and MD (Table II).5 In addition, a list of symptoms and clinical
features potentially related to migraine was determined
through a review of the literature. Data regarding these
migraine-related factors were collected through the question-
naire and on clinical evaluation (Table III). This questionnaire
was provided to patients as part of their clinical evaluation.
Audiograms and vestibular testing (when available) were eval-
uated to assist in the diagnosis of MD. For each patient, the
examiner confirmed the validity of their responses by recheck-
ing the written responses with the patient. All diagnoses were
confirmed by the senior author during the patient encounter.
Patients were then followed up for at least 3 months, and their
Laryngoscope 126: January 2016
164
TABLE I.
The 1995 American Academy of Otolaryngology–Head and Neck
Surgery Diagnostic Criteria for Meniere’s Disease.
Certain Meniere’s Definite Meniere’s disease plus
disease histopathologic confirmation
Definite Meniere’s Two or more definitive spontaneous
disease episodes of vertigo 20 minutes
or longer
Audiometrically documented hearing
loss on at least one occasion
Tinnitus or aural fullness in the
treated ear
Other causes excluded
Probable Meniere’s One definitive episode of vertigo
disease
Audiometrically documented hearing
loss on at least one occasion
Tinnitus or aural fullness in the treated ear
Other causes excluded
Possible Meniere’s Episodic vertigo of the Meniere’s type
disease without documented hearing loss,
or sensorineural hearing loss,
fluctuating or fixed, with disequilibrium
but without definitive episodes
Other causes excluded
response to migraine prophylactic treatment was recorded. A
positive response was considered as at least a 50% reduction in
the frequency and subjective severity of the attack.
Statistical Analysis
The frequencies of patients, who fulfilled the criteria for
definite, probable, and possible MD, as well as patients who ful-
filled the criteria for migraine with and without aura and VM,
were calculated. The prevalence of migraine-related symptoms
and clinical features were also determined in all patients and
among those who did and did not fulfill the IHS criteria for
migraine (non-IHS migraine patients). v2 test was used to make
comparisons between the subgroups based on the IHS criteria.
Fisher exact test was used wherever the v2 test’s assumptions
were not met. As a secondary analysis, three sets of migraine-
related symptoms and clinical features that were similar to
each other were defined (Table IV). Category A included the
sensitivities and motion sickness; category B included family
histories of migraine, MD, or motion sickness; and category C
included head and neck pain associated with various stimuli.
Prevalence of these groups of symptoms was calculated. All sta-
tistical analyses were performed using PASW 18.0 (SPSS Inc.,
Chicago, IL). Because multiple comparisons were made on the
same data, the Bonferroni correction was applied to reduce the
occurrence of type I errors. Therefore, a P value of <.002 was
considered as significant.
RESULTS
Sixty-nine patients with MD comprised our study
sample. Twenty-seven had possible, five had probable,
and 37 had definite MD. The mean age of the patients
was 52 years 6 14 (range, 18–87 years). The female to
male ratio was 26 (70%) to 11 (30%). According to the
IHS criteria, 19 patients (51%) had migraine headaches,
nine (24%) without aura, and 10 (27%) with aura. Fif-
teen patients fulfilled the criteria for VM according to
Ghavami et al.: Migraine Features in Patients With MD
 TABLE II.
The International Classification of Headache Disorders, Third Edi-
tion, Criteria for Migraine With and Without Aura, and Vestibular
Migraine.
Migraine without A. At least five attacks fulfilling
aura criteria B–D
B. Headache attacks lasting 4–72 hours
(untreated orunsuccessfully treated)
C. Headache has at least two of the fol-
lowing fourcharacteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe pain intensity
4. Aggravation by or causing avoidance
of routine physical activity (e.g., walk-
ing or climbing stairs)
D. During headache at least one of the
following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
E. Not better accounted for by another
ICHD-3 diagnosis
Migraine with A. At least two attacks fulfilling criteria B
aura and C
B. One or more of the following fully
reversible aura symptoms:
1. Visual
2. Sensory
3. Speech and/or language
4. Motor
5. Brainstem
6. Retinal
C. At least two of the following four
characteristics:
1. At least one aura symptom spread
gradually over 5 minutes, and/or
two or more
symptoms occur in succession
2. Each individual aura symptom lasts
5–60 minutes
3. At least one aura symptom is
unilateral
4. The aura is accompanied or followed
within 60 minutes by headache
D. Not better accounted for by another
ICHD-3 diagnosis, and transient
ischemic attack has been
excluded
Vestibular A. At least five episodes fulfilling criteria C
migraine and D
B. A current or past history of migraine
without aura or migraine with aura
C. Vestibular symptoms of moderate or
severe intensity, lasting between 5
minutes and 72 hours
D. At least 50% of episodes are associ-
ated with at least one of the following
three migrainous features:
1. Headache with at least two of the fol-
lowing four characteristics:
i. Unilateral location
ii. Pulsating quality
iii. Moderate or severe intensity
Laryngoscope 126: January 2016
TABLE II.
(Continued)
Migraine without A. At least five attacks fulfilling
aura criteria B–D
iv. Aggravation by routine physical
activity
2. Photophobia and phonophobia
3. Visual aura
E. Not better accounted for by another
ICHD-3 diagnosis or by another vestibu-
lar disorder.
ICHD-3 5 International Classification of Headache Disorders, Third
Edition.
the IHS criteria (41% of all patients and 79% of those
with migraine according to the IHS criteria).
The symptoms and clinical features related to
migraine among patients with MD include scalp allody-
nia; family history of migraine; facial, head, or neck pain
when exposed to cold stimuli; and aura-like or dizziness
symptoms when having a migraine (Table III). Sensitivity
to visual motion, light and sound, head motion, smells,
weather changes, or medication was present in 95% of all
patients with definite Meniere’s and 82% of non-IHS
migraine MD patients. Among these, head motion
sensitivity was the most common (84% of all patients
with definite MD). Fifty-nine percent of all and 50% of
non-IHS migraine patients had motion sickness. Head-
ache was also present in 65% and 39% of all and non-
IHS migraine MD patients, respectively. Comparing those
who fulfilled the IHS criteria for migraine and those who
did not, only neck stiffness was significantly different in
incidence (Table III). There were no other significant dif-
ferences after applying the Bonferroni correction.
Thirty-two (87%) patients of the definite MD cohort
had at least one of the symptoms in category A, 19
(51%) patients had at least one of the family histories in
category B, and 33 patients (89%) had at least one of the
symptoms in category C. All 37 definite Meniere’s
patients in our study sample (100%) met at least one of
the above features, had at least one of the symptoms in
category A, one of the family histories in category B, or
one of the symptoms in category C.
DISCUSSION
We found that 51% of the 37 patients with defi-
nite MD had migraine headaches according to the IHS
criteria. Additionally, 48% of the overall MD patients
had VM based on the IHS criteria. Of the 28 patients
who fulfilled the AAO-HNS criteria for MD but did not
fulfill the IHS criteria for migraine, all had symptoma-
tology that was highly suggestive of a migraine
background.
The pathogenesis of the vestibular dysfunction in
both disorders is still unclear. Endolymphatic hydrops is
considered as the main histopathological correlate of
MD, which may have been caused by another patho-
physiologic mechanism. VM is thought to be related to
Ghavami et al.: Migraine Features in Patients With MD
165
 TABLE III.
Prevalence of Symptoms and Clinical Features Related to Migraine Among Patients With Definite Meniere’s Disease and Comparison of Dif-
ferences Between Those Who Fulfilled IHS Criteria for Migraine and Those Who Did Not.
All Patients With Patients Not Fulfilling IHS Patients Fulfilling IHS
Definite MD Criteria for Migraine Criteria for Migraine
P Value*
Clinical Feature Frequency, N 5 37 % Frequency, N 5 18 % Frequency, N 5 19 %

Sensitivity
Visual-motion sensitivity 19 51% 9 50% 10 53% .99
Light sensitivity 20 54% 8 44.4% 12 63% .25
Sound sensitivity 19 51% 9 50% 10 53% .87
Head-motion sensitivity 31 84 7 39% 11 58% .89
Smells sensitivity 11 30% 4 22% 7 37% .33
Weather-change sensitivity 12 32% 6 33% 6 32% .9
Medication sensitivity 8 22% 4 22% 4 21% .93
Any of the above 33 89% 15 83% 18 95% .63
Motion sickness 22 59% 9 50% 13 68% .25
Mental confusion (head fog) 25 68% 10 55.5% 15 79% .12
Family history
Family history of migraine 12 32% 5 26% 7 39% .56
Family history of Meniere’s disease 3 8% 2 11% 1 5% .52
Family history of motion sickness 3 8% 1 5% 2 11% .58
Any of the above 19 51% 8 44% 11 58% .32
History of using medication for migraine 12 32% 4 22% 8 42%
Sinus pain, facial pressure, or headache when 11 30% 2 11% 9 47% .01
exposed to wind or air conditioner
Pain in scalp or face from unusual stimuli 5 13% 0 0% 5 26% .02
History of getting headache when eating ice cream 25 68% 12 67% 13 68% .91
History of sinus headaches 22 59% 8 44% 14 74% .07
Neck stiffness 20 54% 7 39% 13 68% .07
Hearing loss
Sensorineural in at least one ear 35 95% 12 67% 13 68% .91
Mixed hearing loss % 6 33% 9 47% .39
All types of hearing loss 35 95% 16 89% 19 100% .14

*Based on the Bonferroni correction. P values <.002 were considered statistically significant.
IHS 5 International Headache Society.

the neural input of the trigeminal nerve on the vascula-
ture to the inner ear.11 In addition, central vestibular
abnormalities, neurogenic inflammation, and possibly
changes in blood flow may contribute to the effect of
migraine on the inner ear or the symptoms seen in
patients with VM. Specific effects on the peripheral end
organ other than increase in vascular permeability have
not been elucidated.11 Therefore, MD is thought to be a
vestibular end-organ disease, and VM is a central or
peripheral vestibular dysfunction caused by a central
phenomenon. Some MD patients have characteristics
and features that correspond to the VM criteria, and
more interestingly, these patients respond to the same
medications that are used for VM patients.12 The evi-
dence for this treatment effect is currently observational.
Even though this appears to support a similar underly-
ing cause for VM and MD, it could also be partially due
to medication effects that potentially control dizziness
where the two disorders could have different pathophysi-
ologic mechanisms. In our experience, medications with
no apparent effect on dizziness (e.g., calcium channel
blockers and tricyclic antidepressants), have provided
relief in a significant group of patients with MD.
Based on similarities in cervical and ocular
vestibular-evoked myogenic potential (VEMP)
responses,13 Zuniga et al. found that there was no one
VEMP test that distinguished the two diseases. They
theorized that patients with VM might have end-organ
injury in the inner ear, causing endolymphatic hydrops.
They recognized that certain VM patients might actually
be MD patients who do not have large enough of an
audiometric loss to meet the AAO-HNS criteria for MD.
Similarly, it has been found that neither a motion sensi-
tivity questionnaire nor caloric testing could distinguish
MD and VM patients.14 We believe that clinical testing
cannot distinguish MD from VM, possibly due to the
common origin of the two conditions.
The pathophysiology of migraine headaches is par-
tially understood. Migraine aura is believed to be due to
the release of neuropeptides, such as substance P, neuro-
kinin A, and calcitonin gene-related peptide into the
dural circulation,15 with the activation and sensitization

Laryngoscope 126: January 2016 Ghavami et al.: Migraine Features in Patients With MD
166
 TABLE IV.
Migraine-Related Symptoms and Clinical Features Categorization.
Category A Motion sickness
Sensitivity to head motion
Sensitivity to light and sound
Sensitivity to visual motion
Sensitivity to smells
Sensitivity to weather changes
Sensitivity to medication*
Category B Family history of migraine
Family history of Meniere’s disease
Family history of motion sickness
Category C Sinus pain, facial pressure, or headache
when exposed to wind or air conditioner
Pain in scalp or face from unusual stimuli
History of getting headache when eating ice cream
History of sinus headaches
Neck stiffness
*Defined as significant side effects to low doses of many
medications.
of the trigeminal vascular system,16 and subsequent
spreading cortical depression.16,17 Vasospasm in the pos-
terior circulation has been proposed as a mechanism for
migraine-associated damage to the inner ear18–20 and
may underlie some forms of migrainous vertigo. Addi-
tionally, it has been proposed that imbalance and motion
intolerance may result from abnormal central process-
ing, possibly from vasospasm or spreading depression to
the vestibular cortex.21 Stimulation of the trigeminal
nerve with noxious stimuli in guinea pigs caused
changes in vascular permeability in the cochlea and bas-
ilar artery with orthodromic and antidromic activation
of trigeminal sensory fibers.11 From this animal model,
the authors proposed that vertigo, tinnitus, and hearing
deficits associated with migraine could arise by excita-
tion of the trigeminal nerve fibers in the cochlea.
Endolymphatic hydrops is a histopathological diag-
nosis that is not confined to MD, and MD is a clinical
diagnosis that is not always associated with hydrops.22
Other factors, including autoimmune reactions,23 food
sensitivities, and vascular disturbances may play a role
in MD.22 As of yet, there is no clear explanation of why
the hearing loss in MD is in the low frequencies. The
labyrinthine artery, which is usually a branch of the
anterior inferior cerebellar artery, then branches into
the end-organ arteries of the cochlear and vestibular
arteries.24 The cochlear artery supplies the basal turn
primarily and the spiral modiolar artery supplies the
apex and the middle turn. A drop in blood flow to the
cochlea via the spiral modiolar artery has been proposed
to cause a low-frequency hearing loss.25 We conjecture
that endolymphatic hydrops may be the end result of
recurrent assaults to the cochlea from recurrent vaso-
spasms of the spiral modiolar artery, which primarily
supplies the apical turn of the cochlea26 and not an
intrinsic cochlear disorder.
Laryngoscope 126: January 2016
We theorize that MD is most likely a variant of VM
and that the symptoms are a consequence of a migraine
etiology and not an intrinsic inner ear disorder. We
hypothesize that involvement of a combination of the
anterior vestibular artery, vestibulocochlear artery, its
individual branches (cochlear and vestibular arteries),
and the spiral modiolar arteries are affected. The var-
iance in the hearing loss may be due to the difference in
anastomotic patterns among individual patients.26 Some
patients may develop low-frequency hearing loss, some
high, some low and high with preserved mid frequencies
(peak shaped audiogram),27 and some flat.28 A reversible
vasospasm of the spiral modiolar artery alone would
cause only a low frequency sensorineural hearing loss,
and no vestibular symptoms as has been described in
what was previously termed cochlear hydrops. Addi-
tional involvement of the cochlear artery can lead to
high-frequency hearing loss seen in the high- and low-
frequency hearing loss.28 The involvement of the ante-
rior vestibular artery, which supplies the superior canal,
horizontal canal, and the utricle can lead to the more
significant vertigo attacks. Finally, the vestibular artery
involvement can cause dysfunction of the posterior canal
and saccule, which may potentially be the cause of posi-
tional vertigo seen in MD.29 Although this hypothesis
for the pathophysiologic mechanism of this disorder is
unproven and untested, further studies are warranted to
elucidate this mechanism. Potential studies in animals
modeled after the study by the Vass et al. group11 to
selectively stimulate or partially occlude the various
arteries of the inner ear with subsequent histopathologic
examination will help in understanding the pathophysi-
ology. For example, if changes in vascular flow or recur-
rent stimulation of the trigeminal nerve were found to
affect hearing in the animals and cause endolymphatic
hydrops, it could help support the above hypothesis.
All the patients with Meniere’s disease in our
cohort responded to the migraine lifestyle/dietary
changes and migraine prophylactic therapy with control
of their vertigo and stabilization of their hearing. Our
recommendation is that patients with MD and migraine
receive treatment for their migraine disorder. Other
patients, who do not fulfill the criteria for migraine
headaches or VM, should be treated with migraine pro-
phylactic agents prior to surgical or destructive intra-
tympanic therapy. We believe that there may be several
separate types of VM: one that causes hearing loss and
has clinical manifestations of MD via a centrally modu-
lated dysfunction of the cochlear and vestibular arteries
and possibly end organs, and one that does not cause
hearing loss (selective dysfunction of the vestibular
artery or anterior vestibular artery). This second group
of patients is also prevalent in our practice, but is not
described in this study.
CONCLUSION
A majority of patients with MD have migraine
headaches as defined by the IHS. Of those who do not
fulfill the IHS migraine criteria, a majority has charac-
teristics such as a family history of migraine, visual
Ghavami et al.: Migraine Features in Patients With MD
167
motion sensitivity, or lifelong motion sickness that are
highly suggestive of a migraine etiology. All Meniere’s
patients who did not fulfill the IHS criteria for migraine
had either a family history of migraine-related problems,
at least two sensitivities to external stimuli, or atypical
head and neck pain associated with migraine. All MD
patients in our cohort responded well to migraine life-
style/dietary changes and migraine prophylactic therapy,
with control of their vertigo and stabilization of their
hearing. We recommend that patients with MD and
migraine receive treatment for their migraine disorder.
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Ghavami et al.: Migraine Features in Patients With MD